1
Optimizing Health Information Technology
To Promote Opioid Stewardship
Session #133, February 13, 2019
Joanne Hatfield, Pharm.D., BCPS. Clinical Lead Pharmacist – Pain Management, PGY-1
Pharmacy Residency Coordinator, Truman Medical Centers
James Hellewell, MD, MS, Medical Director, Care Transformation Information Systems,
Intermountain Healthcare
2
Joanne Hatfield, Pharm.D., BCPS
James Hellewell, MD, MS
Has no real or apparent conflicts of interest to report.
Conflict of Interest
3
• Truman Medical Centers Pain Management Program
– Service Design and Outline
– Opioid Stewardship Initiatives
– Outcomes
• Intermountain Opioid Safety Initiative
– 2018 Goals
– Technical Solutions
– Outcomes
Agenda
4
• Outline the development of a pharmacist-led inpatient pain
management and opioid stewardship service
• Identify how EHR can play a pivotal role in your pain management
program
• Identify examples of decision support solutions designed to
increase opioid safety how one or more of the ideas shared may
be beneficial to your own organization
Learning Objectives
Truman Medical Centers
Health Sciences District
Lakewood
Behavioral Health
University Health
327K+327K+
Outpatient visits
11,15311,153
Surgical cases
26K+26K+
myTruHealth patient
portal accounts
Inpatient
facilities
22
Level I Trauma Center
600600
beds
6060
clinics
4K4K
employees
625625
medical
staff
3,4283,428
births
87K+87K+
ED visits
1,3951,395
Trauma admissions
22,60222,602
Acute admissions
1,3481,348
nursing staff
88
Community
clinics
6
Where we started
• No inpatient pain management service outside of palliative
care
• Senior Leadership Rounds revealed pain management
concerns continued to affect patient satisfaction
• Outpatient Pain Clinic request for pharmacist involvement
in interdisciplinary clinic
7
• The Joint Commission Sentinel Event Alert #49: Safe Use of Opioids in
Hospitals
– Create and implement processes that allow for a second level
review of pain management plans that include high-risk opioids by a
pain management specialist or pharmacist
• Society of Hospital Medicine Improving Pain Management for Hospitalized
Medical Patients – Implementation Guide
– Establish a core team: Those with expertise in pain management
and quality improvement with nursing, pharmacy and physician
representation
– Ensure safe and appropriate opioid prescribing: consider requiring
specialist pain consultant or pharmacist involvement for high-risk
medications (methadone)
• CDC Guidelines for Prescribing Opioids for Chronic Pain
– Promote integrated pain management and collaborative working
relationships with other providers (e.g., behavioral health,
pharmacists, and pain management specialists)”
Supporting evidence
8
Service design and outline
1 Pharmacist FTE
Opioid Stewardship
Inpatient Pharmacy
Pain Management
Consult
Outpatient
Pharmacy Pain
Management
Consult
9
Opioid stewardship
Electronic Reports
• Discern Analytics - active orders for scheduled opioids and parenteral
opioids
• Power Insight – outpatient short acting opioid prescriptions
Medication Reconciliation
• State Prescription Monitoring Programs (PMP)
• Cerner External RX history
Communicate medication related problems and recommendations to
provider; Suggest pharmacy pain management consult
Other opioid stewardship initiatives
• Opioid IV to PO substitution
• Adjust discharge order sentences to change prescribing habits
• Opioid education embedded in depart process
Opioid IV to PO substitution
11
Order sentence default amounts
12
Inpatient pharmacy pain
management consult
“Pharmacy Pain Management” consult order created
Consult generates in pharmacy multi-patient task list
Perform comprehensive profile review, medication
reconciliation, patient visit and assessment
Document intervention form and progress note in electronic
medical record
Patient is reassessed as needed or until pain management
goals are met
13
• One form per intervention
• Intervention types can be
customized
Pain management intervention form
14
Outpatient pharmacy pain
management consult
Physician places clinic consult order
Order good for up to 1 year
Consult generates in scheduler que
Patient schedules appointment.
40 min new patient, 20 min return visit
Perform MTS within scope of practice
Document intervention form and clinic note in electronic
medical record
15
Results: opioid IV to PO
substitution
0.00
10.00
20.00
30.00
40.00
50.00
60.00
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
2017 2018
Inpatient IV opioid orders Jan 2017 – Nov 2018
average IV orders per day
16
Results – discharge prescriptions
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
2017 2018
Short-Acting Opioid Prescriptions Jan 2017 - Dec
2018
Total opioid prescriptions 5 day supply (%)
17
Results – consult services
• Inpatient consult service
– Average 16 consults
requested by physicians
per month
– Average 2.7 patient visits
per day
• Outpatient consult service
– 8 available appointment
times per day
– 65% scheduled capacity
– 70% show rate
0
5
10
15
20
25
30
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
MD Consults per month
May 2017 – Dec 2018
MD Consults per month
18
Results – pain management
interventions
0
50
100
150
200
250
300
350
Pharmacy Pain Management May 2017 - Dec 2018
No. of Interventions Interventions Accepted (%)
19
• Successes
– Developed a multifaceted pharmacy-driven pain management
program
– Involvement extended beyond consult service:
• TMC Corporate Pain Management Committee
• Palliative Care Team
• Education of multiple disciplines
• Opioid shortages
• Challenges
– 1 Pharmacist FTE
– Acceptance of pharmacy as a pain management provider
– Documentation
Conclusions
Headquartered in
Salt Lake City
Headquartered in
Salt Lake City
Created in
1975
when
LDS Church
donated its
15 hospitals
to the
communities
they served
Created in
1975
when
LDS Church
donated its
15 hospitals
to the
communities
they served
37,000
caregivers
37,000
caregivers
450
volunteer
governing
trustees on
32 boards
450
volunteer
governing
trustees on
32 boards
Integrated Health System
Serving Utah, Southern Idaho and Intermountain West
Integrated Health System
Serving Utah, Southern Idaho and Intermountain West
23
hospitals
with 2,843
licensed
beds
23
hospitals
with 2,843
licensed
beds
2,300
employed
physicians
and advanced
practice
clinicians at
170
clinics
2,300
employed
physicians
and advanced
practice
clinicians at
170
clinics
SelectHealt
h
insurance
plans
with
850,000
members
SelectHealt
h
insurance
plans
with
850,000
members
TeleHealth
Homecare &
Hospice
InstaCare
Connect
Care
Life Flight
Precision
Genomics
TeleHealth
Homecare &
Hospice
InstaCare
Connect
Care
Life Flight
Precision
Genomics
Strong Bond Agency Ratings
S&P: AA+ Moody’s: Aa1
Strong Bond Agency Ratings
S&P: AA+ Moody’s: Aa1
$225 million in charity care
during 2017 (236,000 cases)
$225 million in charity care
during 2017 (236,000 cases)
Quick Facts About Intermountain Healthcare
“Be a model health system”
21
Intermountain 2018 Opioid Safety Goals
22
83% have
discussed risks
53% have
discussed
alternatives
System-wide
prescribing
goals
20,000 lbs.
collected
Source: Centers for Disease Control and Prevention (CDC).
Multiple Cause of Death, 1999-2015
23
Post-operative patients often
prescribed too many pills
Consumption Survey
Post-operative patients
117,000+ surveys
25-30% response consistently
24
• Provide easy access to procedure specific order sentences with
default quantity based on patient survey data
• Quick orders
• Order catalog order folders
• Encourage providing 2 prescriptions of smaller quantity
– Fill one on discharge
– Fill the second later only if needed (use earliest fill date)
Facilitate prescribing fewer pills
post-operatively
Technical Solutions
Surgery
Quick
Orders
26
Acute Therapy Type
• Requires stop date
• Completes after stop
date
• No auto-calculated
supply
Maintenance Therapy Type
• Persists on med list
• Auto-calculated supply
Default Short Acting Opioids to Acute
Therapy Type
27
Decrease Short Acting Opioid
Default Dispense Amounts in Order
Catalog
Dispense amounts
decreased from as high as
60 pills down 12 and 20 pills
and then later decreased to
8 and 12 pills.
28
Update Opioid Prescription Favorites
for Acute Pain
Parameters Updated
• Therapy Type
• Dispense Quantity
• Number of Refills
Clinician Approval
• Widely vetted before any
changes were implemented
Favorites changed from Maintenance to
Acute therapy type
4,230
Favorites changed to 3 days dispense
quantity
2,423
Favorites changed to 0 refills
64
29
• Graph of a patient's daily MME dose over time
• Prescriber alert for new prescription that would cause total daily
dose to exceed 90 MME
• Nurse alert for administration that would cause running 24 hour
amount received to exceed 90 MME
• MME data used in opioid induced respiratory depression risk
calculation
Leveraging Morphine Milligram
Equivalents (MME)
31
Alert When More Pills Are Being
Prescribed Than Recommended for
Acute Pain
Reduce over-prescribing
of opioids for acute pain
by alerting when more pills
are prescribed than
recommended
32
Alert When Multiple Providers Are
Prescribing Opioids and/or
Benzodiazepines
Reduce co-prescribing of
opioids and
benzodiazepines by
alerting providers ordering
an opioid or benzodiazepine
and the patient already has
one of those medications
ordered by another provider
33
Facilitate Coordinating Care of Jointly
Managed Patients
Reduce risk of over-
sedation by alerting non-
pain services clinicians
ordering sedating agents in
patients managed by the
pain services team
Sedating Agents:
• Opioids
• Benzodiazepines
• Muscle Relaxants
• Misc. Sedating Agents
34
Outcomes
35
Joanne Hatfield, PHARM.D., BCPS
Clinical Lead Pharmacist – Pain Management
PGY-1 Pharmacy Residency Coordinator
(816) 404-4416 | joanne.hatfield@tmcmed.org
Joanne-hatfield-546a18134/
James Hellewell, MD, MS
Medical Director, Care Transformation
801-455-5275 | James.Hellewell@imail.org
James-hellewell-72583419/
Questions
